Safety and benefits of using low- management and glycemic control. Is there enough evidence?

Transcription

1 Safety and benefits of using low- calorie sweeteners in weight management and glycemic control. Is there enough evidence? Aimilia Papakonstantinou, PhD RD 2 nd Department of Internal Medicine, Research Institute and Diabetes Center, Athens University, Attikon University it Hospital, Athens, Greece

2 Why do we crave sweetness? The acceptance of sweetness is innate and universal Taste Preferences Our preference for sweets is thought to be a basic survival adaptation Sweetness directs newborn mammals toward safe and nourishing foods and drinks, while bitterness signals potential harm

3 Sugar Preference Shifts From Childhood to Adolescence Hedonic profile, detection threshold, and perceived intensity of sucrose was tested in 143 children (11-15 y) Plasma concentration of several hormones, biomarker of bone growth, body size, puberty stage, dietary habits were measured Children with high and low preference patterns did not differ in sensory aspects of sucrose perception, age, BMI, dietary restraint Change in sugar preference from high to low during adolescence appears to be associated with the cessation of growth Coldwell SE et al. Physiol Behav. 2009; 96:574-58

4 Trends in the use of low-calories sweeteners

5 Are low-calorie sweeteners safe? Is there enough evidence?

6 All things are toxic and there is nothing without poisonous qualities: it is only the dose which makes something a poison Paracelsus Hazard = An inherent property of the molecule which does not take dose-response into account Risk = The likelihood of that property being expressed under relevant exposure conditions

7 Acceptable Daily Intake (ADI) ADI represents the maximum amount of sweetener that can be safely consumed daily over a lifetime without risk. Expressed in mg/kg body weight/day. ADI is a conservative estimate reflecting 1/100 maximum level at which no adverse effects are observed. Fixed by main independent regulatory bodies EFSA JECFA (WHO/FAO) FDA ADI is the approval of a substance after careful examination and evaluation that it is safe to consume.

8 Allowing for inter-species differences and human variability SPECIES DIFFERENCES HUMAN VARIABILITY Total uncertainty (safety) factor = 10 x 10 = 100 The NOAEL is divided by an uncertainty factor of 100-fold to derive the ADI expressed in mg/kg body weight

9 Safety of intense sweeteners Intense sweeteners are amongst the most extensively studied components of our diet The use of high doses in vitro and in animal studies ensures that some hazard will be identified The application of testing guidelines and safety factors (combined with the setting of suitable use levels) ensures that t there is negligible ibl risk at human intakes Despite this the media continually run stories based Despite this, the media continually run stories based on the hazard NOT the risk

10 Safety of low-calorie sweeteners Sugar alcohols and nonnutritive sweeteners are safe when consumed within the acceptable daily intake levels l established by the Food and Drug Administration (A Level of Evidence) American Diabetes Association. Position Statement. Diabetes Care 2009; 32:S13 S61 American Dietetic Association. Position of ADA. JADA. 2004;104: The European Food Safety Authority has once again confirmed the safety of aspartame. The Panel concluded that there is no indication of any genotoxic or carcinogenic potential of aspartame and that there is no reason to revise the previously established ADI for aspartame of 40 mg/kg bw/day April 2009, _ htm

11 Types of sweeteners

12 Types of sweeteners 1. Naturally occurring sweeteners Sucrose (table sugar) SHOULD SUBSTITUTE FOR OTHER CARBOHYDRATES Fructose (honey, fruits, vegetables) ALTHOUGH LOWER POSTPRANDIAL GLUCOSE RESPONSE IS NOT RECOMMENDED AS SWEETENING AGENT DUE TO ADVERSE EFFECTS ON PLASMA LIPIDS Sugar alcohols l (mannitol, xylitol, l maltitol, l sorbitol, isomalt, erythritol, lactitol 2.4 kcal/g) Some found in foods, i.e. sorbitol in apples, pears In large amounts may cause diarrhea esp in children 2. Intense sweeteners often called Artificial i sweeteners But some are naturally occurring plants extracts such as steviol glycosides from the stevia plant

13 Intense sweeteners e e s Replace sweetness normally provided by sugar to provide low calorie or sugar free alternatives. May perform other functions in foods such as humectants, thickeners or emulsifiers. Often contribute to the texture or consistency of products ARE CONSIDERED FOOD ADDITIVES AND ARE STRICTLY REGULATED Prior to their authorisation, food additives are evaluated for their safety by the Scientific Committee on Food, an expert panel that advises the European Commission in questions relating to food.

14 Intense sweeteners Most frequently used sweeteners in the European Union's legislation: 1.Acesulfame-potassium 2.Aspartame 3.Cyclamate 4.Saccharin 5.Sucralose 6. Stevia

15 Acesulfame Potassium 200 times sweeter than sugar Calorie-free Often combined with other sweeteners Not metabolized or stored in body. After consumption, quickly absorbed by body and then rapidly excreted unchanged Heat stable, suitable for cooking and baking Brand Name : Sunett, Sweet One Safety Allowed to be used in foods by European Parliament and Council Directive since June Re-evaluated by EFSA in 2000 ADI (Acceptable Daily Intake) 9 mg/ kg body weight

16 Aspartame times sweeter than sugar Combination of two amino acids (natural protein) Aspartic acid + Phenylalanine Minimal caloric contribution 4 kcal/g due to tiny amount needed MOST STUDIED SWEETENER ON THE MARKET!!! Brand names: NutraSweet, Equal, Canderel Safety Allowed for use in foods by European Parliament and Council Directive since June EFSA re-confirmed safety in 2002, 2006 & 2009 Phenylketonuria (PKU) patients should not consume ADI (Acceptable Daily Intake) 40 mg/kg body weight in EU

17 Cyclamate times sweeter than sugar Most people do not metabolize cyclamate Heat and Cold stable with good shelf-life Safety FDA withdrawn its approval in 1969, based on findings of a controversial study in which h rats were fed an extremely high dose of cyclamate. FAO/WHO Expert Committee on Food Additives (JECFA) 1982 Allowed for use in foods by European Parliament and Council Directive since June EFSA in 2000: ADI (Acceptable Daily Intake) 7 mg/kg body weight

18 Saccharin times sweeter than sugar Not metabolized; calorie-free Heat stable Brand Name : Sweet N Low Hermesetas Safety Allowed for use in foods by European Parliament and Council Directive since June ADI (Acceptable Daily Intake) 5mg/ kg body weight

19 Sucralose 600 times sweeter than sugar Derived from sugar Not metabolized; calorie-free Heat stable Brand Name : Splenda Safety Allowed for use in foods by European Parliament and Council Directive1994. ADI (Acceptable Daily Intake) 15mg/kg body weight

20 Stevia Stevia is a naturally occurring sweetener from plants in the sunflower family. It has a slower onset and longer duration of taste than sugar. It is times sweeter than sugar and has been used for several years in a number of countries as sweeteners for a range of food products. Safety Approved for use by EFSA in 2010 (awaiting for EU Approved for use by EFSA in 2010 (awaiting for EU wide approval expected in 2011)

21 Estimated Daily Intake (EDI) vs. ADI Research shows intakes (EDI) are far below the ADI Ace-K: EDI = 20% of ADI for adults Aspartame: EDI = 6% of ADI in general adult population Saccharin: EDI = 12% of ADI Sucralose: EDI = 32% of ADI for adults and children over 2 years

22 Are low-calorie l sweeteners beneficial for body weight management and blood glucose control?

23 Population study of 6,814 adults Self-reported demographic, clinical and lifestyle characteristics Diet soda consumption assessed by FFQ Incident type 2 diabetes identified at 3 follow-up examinations RESULTS At least daily consumption of diet soda, BUT NOT sugar sweetened beverages, associated with 36% greater relative risk of metabolic syndrome and 67% greater relative risk of incident type 2 diabetes compared with nonconsumption Associations bt diet soda intake and type 2 diabetes independent of adiposity or change in body weight, whereas associations bt diet soda and metabolic syndrome were dependent on adiposity

24 Diabetes Care 2009; 32: Self-reporting on lifestyle is always a limitation because people often underestimate or overestimate body weight, food consumption, and habits 2. Population studies cannot offer a cause-effect relationship 3. The association bt diet soda consumption and metabolic syndrome was not significant with adjustment for measures of adiposity (waist circ and/or BMI). This was not the case with type 2 diabetes. 4. However, authoritative bodies on diabetes, such as International Diabetes Federation, state that the risk factors for type 2 diabetes include age, obesity, family history, physical inactivity, race/ethnicity, impaired fasting glucose or impaired glucose tolerance, and prior gestational diabetes. 5 There is NO evidence that any single food or beverage increases 5. There is NO evidence that any single food or beverage increases the risk for type 2 diabetes

25 But 3 major questions that arise are: 1. How does consumption of a beverage containing no significant calories increase the relative risk of diseases that are primarily associated with family history and obesity????? 2. How does a diet soda increase blood sugar levels???? 3. How does a liquid that is low in energy density contribute to diabetes and metabolic syndrome????

26 Effect of Portion Size on Energy Intake Amo ount co onsum ed (g) Portion of Macaroni & Cheese Consumed (g) Rolls et al. Am J Clin Nutr Dec;76(6):

27 Discrepancy Between Reported and Actual Energy Intake and Expenditure Energy Intake Energy Expenditure * Kcal/ /d * Reported Actual Reported Actual *P<0.05 vs reported. Lichtman et al. N Engl J Med 1992;327:1893

28 Effects of fat and water content on energy density 100 Corn oil Ltt Lettuce (g/100 0 g) Fat content r 2 = Apple r 2 = Butter Steak Bacon Cheese 50 Cheese Lettuce Steak Bread Milk 30 Bacon 30 Apple chocolate 20 Milk chocolate 20 Bread Pretzels 10 Pretzels Energy Density (kcal/g) ent (g/1 100 g) Wate r conte50 Butter Corn oil Energy Density (kcal/g) Rolls and Bell. Med Clin North Am 2000;84:401

29 Diet energy density, independent of fat content, influences energy intake of Food ed (g/d d) Weight o onsume W Co f Food al/d) ntent of d (k/ca rgy Con nsumed Ener Co Energy Density (kcal/g) *P< versus other 2 groups. Fat content held constant. Bell et al. Am J Clin Nutr 1998;67:412 * Energy Density (kcal/g)

30 Cutting energy density and portion size decreases intake Rolls et al. AJCN 2006;83:11-17

31

32 Lifestyle interventions (Diet + Exercise) Reduce Rate of Progression to Type 2 Diabetes by 49% in People with Impaired Glucose Tolerance (Ν=8084), Whereas Drug Treatment Reduces Rate by 30%. Gillies CL et al. BMJ. 2007;334:

33 Does the use of sweeteners enhance appetite and energy intake? 2 satiety t studies in 80 s by Blundell ll raised question of increased hunger (2007 Blundell study finds no increase in hunger among habitual lowcalorie sweeteners users) Parallel rat study by Davidson and Swithers (2008) suggest increased hunger and intake (small sample 10 rats, speculative nature animal studies not applicable in humans, saccharin is much sweeter than glucose) BUT Rolls (1991) Reviewed 45 studies Evaluated low calorie sweeteners on hunger, appetite, food intake if intense sweeteners are part of a weight control program, they could aid calorie control by providing palatable foods with reduced energy. It needs to be stressed that there are no data suggesting that t consumption of foods and drinks with intense sweeteners promotes food intake and weight gain in dieters.

34 Does the use of sweeteners enhance appetite and energy intake? Several studies have assessed the effect of low-calorie sweetener consumption on actual food intake None has shown an increase Studies showed that consumption of low-calorie sweeteners did not lead to increases in self-rated appetite Mattes R. Physiol Behav. 1990;47: ; Canty D & Chan M. Am J Clin Nutr. 1991;53: Drewnowski A et al. Int J Obes Relat Metab Disord. 1994;18:570-8 Drewnowski A et al. Am J Clin Nutr. 1994;59:338-45

35 Effects of stevia, aspartame, and sucrose on food intake, satiety, and postprandial glucose and insulin levels Subjects = 19 healthy lean Participants individuals and consumed 12 obesesig less food over Consumed entire 400 day g in preload stevia and aspartame sweetened conditions with ostevia, compared to sucrose aspartame or sucrose 20 before Stevia lunch vs and Sucrose dinner = meals kcal Aspartame Meals were vs Sucrose consumed = -ad 334 kcal libitum No difference between stevia and aspartame Participants reported hunger and satiety levels, before, after No compensation for lower energy and every 30 until next meal from preloads in later Blood samples collected meals before and at 30, 60, 120 min Preloads following containing test meal aspartame more pleasant taste than those containing stevia and sucrose Anton SD et al. Appetite. 2010;55:37-43

36 Bellisle and Drewnowski (2007)

37 Bellisle and Drewnowski (2007) Energy density, satiety and the control of food intake with low calorie sweeteners Previous studies failed to show that intense sweeteners stimulate appetite or have an adverse effect on satiety. Conclusion: low-calorie sweeteners are not appetite suppressants and will not result in automatic weight loss The ultimate effect of low-calorie sweeteners is dependent upon their integration into a whole lifestyle approach.

38 Meta-analysis of 16 studies Exchanging foods containing aspartame instead of sucrose leads to significant reduction in energy intake and body weight Reduction of energy intake 222 kcal/day ->-> Weight loss ~0,2 kg/week Equivalent to 10 kg in a year A. de la Hunty et al. Br Nutr Foundation Nutr Bulletin 2006; 31:

39 Rodearmel et al. Pediatrics 2007;120:e869-79

40 2 cohorts of America on the Move overweight children. America on the move (AOM) intervention group: (N=100) add 2000 steps daily (pedometer) and reduce caloric intake by ~100 kcal/day by replacing sugar with sucralose, for 6 months Self-Monitor (SM) (N=92) Maintain normal America on the Move practices and sugar intake for 6 months. Goal: Maintain or reduce BMI. Rodearmel et al. Pediatrics 2007;120:e869-79

41 Results AOM children who cut 100 Kcal/day substituting sucralose (Splenda) for sugar had a greater reduction in BMI-for-age z score over 6 months compared to SM controls. Rodearmel et al. Pediatrics 2007;120:e869-79

42 A greater proportion of AOM children maintained or reduced their BMI-for-age, and fewer AOM children increased BMIfor-age. Rodearmel et al. Pediatrics 2007;120:e869-79

43 Aspartame and weight control trial. N = 163 obese women Two groups: aspartame vs. no aspartame in diet Followed identical low-energy weight-loss diets for 19 wks ADA recommended diet components: 1000 ± 200 kcal/day 200 min/wk walking minimum 1 year maintenance 1500 ± 300 kcal/day 2 year follow-up Blackburn et al. AJCN 1997, 65:409-18

44 Blackburn et al. AJCN 1997, 65:409-18

45 Why are low-calorie sweeteners effective in weight loss/maintenance? Exchanging low-calorie sweeteners for sucrose creates an energy deficit without later calorie compensation Review of calorie intake records reveal aspartame users consumed ~167 fewer calories per day than nonusers

46

47 Conclusions

48 Role of Low-calorie Sweeteners in Body Weight Management and Blood Glucose Control Are safe to consume within the acceptable daily intake levels Substituting full-calorie foods and beverages, results in fewer calories consumed Sweet taste no or few kcal Do not affect blood glucose levels More low calorie food choices, therefore increased satisfaction with eating plan Reduce the energy density of the diet without any loss of palatability Blackburn G. World Rev Nutr Diet. 1999;85:77-87; American Dietetic Association. Position of ADA. JADA. 2004;104:

49 THANK YOU FOR YOUR ATTENTION!!!! ANY QUESTIONS????